Document Sample
TPA_form_for_solicitors Powered By Docstoc

             Please return this form to:
             UK Information Centre
             Motor Insurers’ Bureau
             Linford Wood House
             6-12 Capital Drive
             Linford Wood
             Milton Keynes                                                                                         DX: 142620
             MK14 6XT                                                                                        Milton Keynes 10

             BEHALF OF A CLIENT
                                     TPA - form for a solicitor / representative
             Your reference
             Your name
             Your telephone number
             *Your company name

             *Your company address

             *Your client’s name & address

             * Your client’s day time phone no.
             * What was your client’s                                  Motorist / Cyclist / Pedestrian / Passenger /
             involvement in the accident?                              Property Owner/Other – please specify:

             * Your client’s VRM (if applicable)
             * Date of accident
             * Time of accident
             * Where did the accident

             * Road name / number
             * Nearest Town / City
             * VRM of Third Party Vehicle
             Third Party Vehicle Make
             Third Party Vehicle Model
             Third Party Vehicle Colour
             Third Party’s Name (if known)
             Third Party’s Address (if known)

             Third Party’s Postcode (if known)
             *Briefly describe what happened?

             * These must be completed to allow MIB to verify the legitimacy of your client’s enquiry.
             It may be an offence, under the Data Protection Act 1998, to attempt to obtain information
             without reasonable cause.

Motor Insurers’ Bureau A Company Limited by Guarantee - Registered in England at the address below - No 412787
Linford Wood House, 6-12 Capital Drive, Milton Keynes MK14 6XT
Tel: 0845 165 2800 Fax: 01908 230 221 DX: 142620 Milton Keynes 10 Email:

      The record of your enquiry will be retained, in case of a claim arising against the Motor
      Insurers’ Bureau (MIB). Please note that the existence of a record of insurance on the MID
      is not proof of insurance but merely indicative that a policy may have been in force.

      I enclose a cheque for £10.00 made payable to Motor Insurers’ Bureau.

      If no record is found on the MID it may be possible to submit a claim to the Motor Insurers’
      Bureau. A claim form may be obtained by calling 01908 830001 or by downloading from
      the website:

      Signed ____________________________________ Date _______________________

                                                                                                     Page 2 of 2